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Clopidogrel in Orthopaedic patients: a review of current practice in Scotland
Jibu J Joseph1, Anand Pillai, Diane Bramley
1Department of Orthopaedic Surgery, Southern General Hospital, 1345 Govan Road, Glasgow, Glasgow, G51 4TF, Scotland, UK. jibujohnjoseph@doctors.org.uk
Insights
Current guidelines for stopping clopidogrel bisulfate before surgery are not based on orthopaedic patients. This study found no increased bleeding in patients who continued clopidogrel peri-operatively, suggesting a need for updated guidelines.
Area of Science:
- Orthopaedic Surgery
- Pharmacology
- Vascular Medicine
Background:
- Clopidogrel bisulfate is an antiplatelet medication used to prevent ischemic events in patients with vascular disease.
- Current recommendations advise withholding clopidogrel bisulfate for 7 days before surgery, but these are not derived from orthopaedic patient data.
Purpose of the Study:
- To survey current orthopaedic practice regarding clopidogrel bisulfate cessation.
- To assess compliance with existing guidelines and identify variations in practice among orthopaedic surgeons in Scotland.
Main Methods:
- A questionnaire was distributed to orthopaedic consultants in Scotland.
- Data were supplemented by contacting haematology departments, manufacturers, and conducting a database search.
Main Results:
- A 60.7% response rate was achieved, with 84.7% of respondents encountering patients on clopidogrel bisulfate.
- While 86.1% stopped the medication 5-21 days pre-operatively, 13.9% did not routinely stop it. Increased bleeding was reported by 22.6% but only in those stopping clopidogrel bisulfate more than 7 days prior.
- Nearly half of units had a policy, but most did not consult haematology.
Conclusions:
- Existing recommendations for clopidogrel bisulfate cessation pre-surgery are based on cardiothoracic data, not orthopaedic practice.
- The survey suggests no increased bleeding risk for orthopaedic patients continuing clopidogrel bisulfate peri-operatively.
- A lack of consensus persists among orthopaedic surgeons regarding optimal clopidogrel bisulfate management, necessitating updated, evidence-based guidelines for orthopaedic patients.
Background:
Clopidogrel bisulfate is an antiplatelet agent used to prevent ischaemic events in patients with vascular disease. Current guidelines recommend withholding clopidogrel for 7 days pre-operatively. However these are not based on orthopaedic patients. We therefore decided to survey current orthopaedic practice to see whether this complied with available clinical data.
Method:
A questionnaire was sent to all orthopaedic consultants in Scotland. Four haematology departments, and the manufacturers, were contacted to ask for their recommendations, and a database search was performed.
Results:
140 questionnaires were sent with a 60.7% response. 84.7% of respondents have encountered patients on clopidogrel. Of those, 13.9% did not routinely stop it, and 86.1% stopped it 5-21 days pre-operatively (47.2% at 7 days).45.9% had a unit policy on stopping clopidogrel, and the majority (69.4%) did not consult their haematology department prior to instituting their policy.Increased peri-operative bleeding was the most reported complication (22.6%). However this was only noted in those who stopped clopidogrel greater-than 7 days pre-operatively. Haematology advice ranged from continuing clopidogrel peri-operatively to stopping it 7 days pre-operatively and starting low-molecular-weight-heparin for thrombo-prophylaxis. The manufacturers suggested stopping clopidogrel 7 days pre-operatively. An internet search did not reveal any data on the effect of clopidogrel peri-operatively in orthopaedic patients.
Discussion:
Recommendations on stopping clopidogrel have evolved from studies conducted on patients undergoing cardio-thoracic surgery. There is no data available on the effect of clopidogrel in orthopaedic practice. Our survey indicates that increased bleeding has not been found in patients who continue clopidogrel peri-operatively. Almost half of respondents complied with current recommendations, stopping clopidogrel 7 days pre-operatively. However there remains a lack of consensus amongst orthopaedic surgeons.Currently elective patients should stop clopidogrel 7 days pre-operatively, and emergency patients should stop clopidogrel on admission, however their operation should not be delayed due to clopidogrel usage.
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